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8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 1/19Ingmar Rosen, MD: Jan. 17, 2008
Amplitude integrated EEGbeyond the NICU
Ingmar RosénDivision of Clinical NeurophysiologyDepartment of Clinical Science Lund
Lund University
•Restoration of EEG background
•Detection of seizure events>> SEPrior and Maynard
Old CFM in neonatal monitoring
10 daysof CFM !
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 2/19Ingmar Rosen, MD: Jan. 17, 2008
Old CFM-problems
• Artefacts (movements,care procedures,
ECG, high frequency ventilation)
• Lack of correllation with the original EEGsignal.
• Neonatal aEEG interpretation became anart of its own, independent of the vastEEG-knowledge/experience
CFM/aEEG development
New aEEG/EEG
• Shows the real EEG
• Stores digital EEG, available for review
and reanalysis
• Flexibility – trends, number of
channels, time resolution
New aEEG/EEG monitors by: BrainZ,Viasys, Olympic, Micromed, Day One
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 3/19Ingmar Rosen, MD: Jan. 17, 2008
Patterns discernable by simplified
aEEG/EEG monitoring
• Pathology of EEG background-prognosis
• Monitoring before-during-afterhypothermia
• Seizure patterns-possibility to treat
Applications of aEEG trend monitoring in
paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus and follow up ofacute treatment
• Detection of rare seizure patterns in immobilizedchildren
• Useful tool in full video-EEG monitoring
• Contributes to prognosis after severe ishemic
insult/cardiac arrest
aEEG and SE monitoring
• The additional value of aEEG monitoring is
depending upon type and EEG features ofthe SE
• An early full EEG is recommended and isoften used for tailoring the monitoring
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 4/19Ingmar Rosen, MD: Jan. 17, 2008
EEG message in SE
High intensityseizure pattern
Risk of excitotoxic
injury
Repetitive focalor generalizedspiking
Immediate interferencewith cognition/consciousness
ESESCSWSEpileptic encephalopathyof childhood
Deleterious plasticeffects on brainfunctional development
Progress of generalized convulsive SE
(Treiman)
Start of clinical seizure
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 5/19Ingmar Rosen, MD: Jan. 17, 2008
Continuous generalized seizure pattern
EEG
Seizurepattern arrested by propofol
Continuous EEG
EEG
Seizurepattern arrested by propofol
Burst-Suppression pattern
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 6/19Ingmar Rosen, MD: Jan. 17, 2008
Status epilepticus (AD-2003)
• 4 y girl
• Olfactory neuroblastoma, posteriorfossa+front dx
• Post op unconscious suspected seizures
• Full EEG
• 2 channel aEEG/EEG monitoring
AD-2003
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 7/19
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 8/19Ingmar Rosen, MD: Jan. 17, 2008
Focal seizures and limitednumber of recording channels
How serious is the problem ?
With tailored design sufficient sensitivity isattained with few recording channels (and
electrodes)
The brain is a volumeconductor
P3-P4
C3-P3
C4-P4
A
B
C
3 focalseizureswith different locations all appear in one channel aEEG trace
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 9/19Ingmar Rosen, MD: Jan. 17, 2008
TN (severe epilepticencephalopathy)
• Girl born 34+5 w. Pre-eclampsia.
• 6d gen seiz ; Phbarb, Fos-phen, Midazol.• Seizure free from 10 d
• 2 m foc seiz left eye+ hand + gen ton s
• Repeated seizure periods
• 5 m EEG: Hypsarrythmia. Therapy resistent
• 11m Ketogenic diet with some improvement;several seizure types
TN 2 m seizure
TN 2 m ii
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 10/19Ingmar Rosen, MD: Jan. 17, 2008
TN 2 m i
TN 11 m
TN 11 m
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 11/19Ingmar Rosen, MD: Jan. 17, 2008
aEEG and SE monitoring
• The additional value of aEEG monitoring is dependingupon type and EEG features of the SE
• An early full EEG is recommended and is often used fortailoring the monitoring
• Flexibility of channel number, position, and trend mode isan advantage
• 2 channel (F3-P3; F4-P4) aEEG/EEG recordingrecommended after the neonatal period
Acute EEGFinal
SumupMonitortailored
Monitor
standardEEG
FinalSumup
Green hours
Red hours
Monitor
tailored
Seizure detection (EK-2007)
• 7 m girl with achondroplasia
• Decompressive surgery posterior fossa
• Post op hiccups and apnoeic episodes• Full EEG: diffuse slowing-no epileptiform
activity
• Seizures ?
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 12/19Ingmar Rosen, MD: Jan. 17, 2008
EK-2007
1
2
3
1
2
3
EK-2007
Suspected seizures (AG-2003)
• 4 y girl from Kosovo
• Severe perinatal cerebral lesion
( mechonium aspiration reported)
• Severe dystonic CP
• Microcephaly with extensive cortical and whitematter lesions
• EEG: pathological with interictal positive sharpwaves right side
• Frequent attacks of extension –seizures ?
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 13/19Ingmar Rosen, MD: Jan. 17, 2008
AG-2003
AG-2003
AG-2003
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 14/19Ingmar Rosen, MD: Jan. 17, 2008
AG-2003
Video-EEG(HL-2002)
• 5y girl
• Short history of focal epilepsy
• Subtle episodes with absense sometimesdrawling, sometimes subtle jerks right partof face.
• Tumor left hemisphere (PAD: multifocalmalignant PNET)
HL 2002 vEEG
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 15/19Ingmar Rosen, MD: Jan. 17, 2008
aEEG monitoring of recoveryafter global brain ischemia
Watanabe
Prior and Maynard
Acuteeffects of global brain ischemia and recovery
Gavilanes
CA+ROSC Normothermia Neurol ex Neurol ex
Targettemp
Cooling Rewarm
4h 24h 8h 24h 48h
ContinuousaEEGmon
2chC3-P3C4-P4
SSEPMR
SSEPMR
11
2
33
4
EP
N13
P14
N18
N20
P25 1 uV10 ms
EP N13
P14
N18
N20/P25
iE-cE
C5-cE
Fz-cEcCP-Fz
Continuous aEEG/EEG monitoring duringand after hypothermiatreatmentfollowing cardiac arrest in adults- study designRundgren, Rosén, Friberg. Intensive Care Medicine 2006
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 16/19Ingmar Rosen, MD: Jan. 17, 2008
A B
C D
Flat S-B
Continuous
SE
34 patients
CPC1: 112:63:3
ContinuousEEG
withoutESE
n=20
Flat: 5SB: 3
ESE: 6
CPC1-3:05:14
Table 1: Cerebral Performance Category (CPC) scale
CPC 1: Good cerebral performance: conscious, alert, able to work
CPC 2: Moderate cerebral disability: conscious, can carry out independentactivities
CPC 3: Severe neurological disability: conscious, dependent on others for dailysupport
CPC 4: Coma or vegetative state
CPC 5: Dead
Conclusion
• Continuous simplified aEEG monitoring is
technically feasible in the adult ICU
• The EEG pattern at normoterm (36h) butnot within the first few hours predicsoutcome in terms of survival
• Continuous epileptiform activity with onset
within 24 h after CA is a serious predictivesign.
Rundgren,Rosén,FribergIntCare Med 2006
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 17/19
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 18/19Ingmar Rosen, MD: Jan. 17, 2008
aEEG-monitoring after severeasphyxia and cardiac arrest
(EL-88)
• Girl 17 y• Came under a dead horse during horse
competition
• RLS 8 when rescucitated after 15 min.
• Hypothermia treatment for 48h
0 d
2 d
EL-88
1 d
aEEG-monitoring after cardiacarrest (ZE-91)
• 16 y boy
• Ventricular fibrillation
• Rapid rescusitation-45 min to spont.cirk.• Initially unconscious
• Hypothermia treatment
8/7/2019 Rosen - aEEG beyond the NICU (2)
http://slidepdf.com/reader/full/rosen-aeeg-beyond-the-nicu-2 19/19
1 d
2d
ZE-91
Applications of aEEG trend monitoring in
paediatric neurology beyond the NICU
• Monitoring of Status Epilepticus
• Detection of rare seizure patterns in immobilizedchildren
• Useful tool in full video-EEG monitoring fordetection of clinically silent seizures
• Adds prognostic information after severeischemic insult/cardiac arrest
• Full EEG and aEEG/EEG combined isimperative in most cases
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